IV Certification Course

Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you applied to the IV course before? *

Yes

No

Have you attended this school before? *

Yes

No

If yes,

Did you graduate ?

Yes

No

Date of Birth *

MM

DD

YYYY

Are you able to gain employment in the U.S? *

Yes

No

Are you a Veteran? *

Yes

No

Are you working with WorkSource or another financial partner to assist with tuition funding? *

Yes

No

If you are receiving State or Federal assistance such as TANF or SNAP benifits, you may be eligable for tuition assistance opportunities *

Are you interested in learning more about tuition assistance resources ?

Yes

No

Are you currently employed in a healthcare facility? *

Yes

No

Emergency Contact *

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

For the IV Certification Course, student should anticipate 8 hours of lecture and lab time over 1-2 days and a minimum of 1 hour of independent learning as homework *

I understand

Yes

No

Students must comply with RSP code of conduct policies including, but not limited to, Attendance Policy and Behavior Policy. *

I understand,

Yes

No

There are documents required with this application that need to be send directly to ajones@roguesp.org. These documents include photo ID, proof of High School graduation or equivalency, and current resume. *

I understand,

Yes

No